Project Summary

This project is ongoing and does not have results.

The Patient-Centered Outcomes Research Institute (PCORI) seeks to understand the evidence on the impact of doula support during pregnancy, childbirth and in the postpartum period among pregnant, birthing or postpartum individuals to inform our future research investments and objectives and support PCORI’s priority research topic of maternal morbidity and mortality. In addition to PCORI’s programmatic needs, PCORI aims to support decisions of healthcare professionals, policy makers and healthcare organizations with timely and high-quality evidence about preventing maternal morbidity and mortality.

Background

A doula is a trained maternal support professional who offers emotional, informational and/or psycho-social care during pregnancy, childbirth and/or the postpartum periods. Doulas do not replace but complement the role of clinicians (physicians, midwives and nurses). They do not perform clinical or medical tasks, provide medical advice or intervene in clinical care. Doulas are sometimes described by the activity for which they are providing support (e.g., birth doula, prenatal doula, breastfeeding doula and postpartum doula).1,2

The use of doula care is supported by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.3,4 However, even though some prominent U.S. medical societies support doula care, doulas themselves sometimes report poor acceptance from other maternity care providers.5

In the United States, the majority of doulas are private or self-employed. However, community-based and hospital doulas, who may provide services at no cost, for a nominal fee or on a fee-for-service basis, are also available in some areas.5-7 Some community-based nonprofit organizations offer doula support at low or no cost.8-9 A growing number of states have passed legislation allowing Medicaid to reimburse doulas for services, and several states have shown interest in expanding legislation requiring private insurance to cover doula care.5,7-9

Older quantitative systematic reviews6,10-12 have examined the impact of doula support in the prenatal period, as well as during labor and childbirth. Support from a doula during labor and childbirth has been associated with increased maternal engagement, higher patient satisfaction with care, lower rates of cesarean birth, fewer obstetric interventions, fewer complications during labor, less pain medication use, shorter labor hours, lower prevalence of poor five-minute Apgar scores and lower birth costs.6,10-12 However, maternal outcomes associated with doula support during the postpartum period have not been well studied, and the impact of the specific timing and length of doula support has also not been well established. A preliminary scoping of the literature on this topic (impact of doula care during the postpartum period and the impact of the timing and length of support) indicates that there are no comprehensive, quantitative, high-quality evidence syntheses.

Recent policy literature in the United States emphasizes the importance of doula care especially for minorities and less advantaged populations.5,7-9 To our knowledge, no recent systematic review has undertaken the topic of doula support using a health equity perspective.

There is a need to better understand the impact of doula support throughout pregnancy, childbirth and the postpartum period and among different populations. A PCORI-funded review would update previous findings on the impact of doula care in the prenatal period and childbirth with newer literature, as well as examine the impact of doula support in the postpartum period and apply a health equity lens.

Proposed Key Questions (KQs)

  1. What is the impact of doula support on birthing person and infant outcomes compared to usual care?
  2. Does doula support that includes the prenatal and/or postnatal period lead to better outcomes than doula support only offered during childbirth?
  3. Does the impact of doula support during the prenatal and/or postpartum period vary by intensity of care (e.g., number of visits or duration of visit)?

For both key questions, how do the findings vary for birthing individuals at risk for health disparities (Black, Indigenous and people of color; Medicaid beneficiaries; individuals with low income; rural dwelling or urban dwelling persons; immigrants or refugees; those living in unstable conditions; those with comorbid conditions; individuals with low socioeconomic status; persons with a disability; those with a history of trauma; or individuals with limited English proficiency), those medically at high risk and those residing in the United States?

More on This Systematic Review


Public Input for Draft Systematic Review Key Questions

From Mar. 1-22, 2024, PCORI sought input on this systematic review's draft key questions and PICOTS (population, interventions, comparators, outcomes, timing and settings) to better understand the evidence base in order to inform the broader health care community and our future research investments.

Learn More

The Research Protocol will be posted upon registration.

PCORI Systematic Reviews


Learn more about the other PCORI-commissioned systematic reviews here.

Project Information

Meera Viswanathan, PhD
RTI International
$386,506

Key Dates

April 2025
2023

REFERENCES

  1. Steel A, Frawley J, Adams J, Diezel H. Trained or professional doulas in the support and care of pregnant and birthing women: a critical integrative review. Health Soc Care Community. 2015 May;23(3):225-41. doi: 10.1111/hsc.12112. Epub 2014 Jun 19. PMID: 24942339.
  2. Kozhimannil KB, Vogelsang CA, Hardeman RR, Prasad S. Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. J Am Board Fam Med. 2016 May-Jun;29(3):308-17. doi: 10.3122/jabfm.2016.03.150300. PMID: 27170788; PMCID: PMC5544529.
  3. ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol. 2019 Feb;133(2):e164-e173. doi: 10.1097/AOG.0000000000003074. PMID: 30575638.
  4. Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711. 
  5. Knocke K, Chappel A, Sugar S, De Lew N, Sommers BD. Doula Care and Maternal Health: An Evidence Review. (Issue Brief No. HP-2022-24). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. December 2022.
  6. Fortier JH, Godwin M. Doula support compared with standard care: Meta-analysis of the effects on the rate of medical interventions during labour for low-risk women delivering at term. Can Fam Physician. 2015 Jun;61(6):e284–92. PMCID: PMC4463913.
  7. National Partnership for Women & Families (2022). “Improving Our Maternity Care Now Through Doula Support”. Retrieved October 26, 2023, from https://nationalpartnership.org/report/doula-support/
  8. Elevance Health Public Policy Institute (2022). “Addressing Maternal Health Disparities: Doula Access in Medicaid”. Retrieved October 26, 2023, from https://www.elevancehealth.com/public-policy-institute/addressing-maternal-health-disparities-in-medicaid 
  9. Doula Medicaid Project. (n.d.). National Health Law Program. Retrieved October 26, 2023, from https://healthlaw.org/doulamedicaidproject/
  10. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013 Jul 15;7:CD003766. doi: 10.1002/14651858.CD003766.pub5. Update in: Cochrane Database Syst Rev. 2017 Jul 06;7:CD003766. PMID: 23857334.
  11. Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017 Jul 6;7(7):CD003766. doi: 10.1002/14651858.CD003766.pub6. PMID: 28681500; PMCID: PMC6483123.
  12. Myers ER, Sanders GD, Coeytaux RR, McElligott KA, Moorman PG, Hicklin K, Grotegut C, Villers M, Goode A, Campbell H, Befus D, McBroom AJ, Davis JK, Lallinger K, Fortman R, Kosinski A. Labor Dystocia. Comparative Effectiveness Review No. 226. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ Publication No. 29-EHC007. Rockville, MD: Agency for Healthcare Research and Quality; May 2020. DOI: 10.23970/AHRQEPCCER226.

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Last updated: May 9, 2024